Common-sense skin care

Caring for elderly skin is an ongoing challenge in long-term care. Because aging skin is thin, fragile and less resilient, it's more susceptible to dryness, tears, ulcers, rashes, bruising and other forms of breakdown and irritation.

And the problems don't end there. Incontinence, limited mobility, medication use, nutritional status and cognitive decline, among other issues, can further impair skin's protective qualities. Couple that with long-term care's high turnover rates and limited resources — not to mention higher resident acuity and the limited availability of certified skin care experts — and it becomes clear why keeping residents' skin healthy and intact may sometimes seem like an exercise in futility.

“One of the biggest barriers to effective skin care practice is when we don't have programs to prevent skin breakdown in the long-term care settings,” said Jane Kirk, MSN, RN, CIC, clinical specialist for GOJO Industries Inc. “We need to be more proactive in skin breakdown prevention, so there can be less reactive behavior after the wound has happened.”

No question, a reactive approach to skin care is detrimental to both resident and provider alike. Not only can skin breakdown cause significant pain and suffering for the resident, but it also can be difficult — and costly — to treat.
Managing just one pressure ulcer can cost anywhere from $2,000 to $40,000, depending on the stage of development. And if reconstructive surgery is required, that can add roughly $25,000 more per case, the Agency for Health Care Policy and Research and the National Pressure Ulcer Advisory Panel report. What's more, providers will be on the hook for the bill if the wound occurred on their watch and was deemed preventable.

Targeted team training
To overcome pervasive skin care-related challenges, many long-term care providers are improving their approach with comprehensive, ongoing education and multidisciplinary involvement. They make a concerted effort to tap all their available training resources.

“I'm a firm believer that good skin care is something that can be achieved through good training and support,” said Sheryl Hayes, assistant director of nursing and educator at Sanctuary at the Shore, a Trinity Senior Living community in Grand Haven, MI. “I also believe you can have success without a certified wound specialist on hand. Frontline workers can be very successful at preventing homegrown skin issues. They just need the right information and tools.”

Hayes has witnessed that success at her own facility. Even in the absence of a certified wound care specialist, Sanctuary at the Shore has managed to largely prevent new skin breakdown, while also successfully halting more advanced complications in residents who were admitted with pressure ulcers, tears and other skin-related issues.

“I educate all incoming nurse aides during orientation so they understand the importance of prevention and early detection of skin issues, and then I make sure that the training is ongoing. This is important because they're the ones who will usually spot changes in the skin first,” Hayes noted, adding that frontline caregivers also are trained to reposition residents at least every two hours and carefully inspect skin during changes, bathing and other activities. “I teach them the difference between blanchable and nonblanchable redness on the skin, for example, and I teach them to really trust their instincts. If they think something doesn't look right, we want them to act on that gut feeling.”

Recognizing that good education comes in many different forms, Sanctuary at the Shore has worked to build a strong foundation of support. Hayes seeks expert advice from a nurse educator available through the facility's contracted pharmacy. “If we go to her with a particular question or issue and she doesn't have the knowledge herself, she'll find someone who does.”

Sanctuary at the Shore also consults with an orthopedic surgeon who is certified in wound care and can assist staff when a resident is admitted to the facility with a particularly challenging wound.

Many support sources
Hayes also relies on training videos and the Annual National Database of Nursing Quality Indicators, which provides a library of skin care and wound-related education and best practices to aid care and decision-making.

“And don't forget about your vendors. They can be a terrific educational resource,” she added. “They can offer clinical support, [evidence-based literature] and in-services to help frontline workers stay one step ahead with both prevention and treatment of skin breakdown.”

Vendor education has become more multi-layered and flexible by design. Programs such as GOJO's The C.A.R.E. Solution Director of Nursing Toolkit, for example, feature a DVD created by long-term care nurses that teaches nurse aides to properly assess and care for residents' skin.

This evidence-based program was created so viewers can either complete a few sections at a time or finish the whole DVD in one sitting. This type of training can go a long way toward maximizing caregivers' time, Kirk said.

“By instilling a prevention mentality, staff are on the lookout for signs of skin breakdown before there is a problem,” she said. “They understand that taking a moment to report an abnormal finding will save them time in the long run. Another benefit of preventative measures and early detection of skin breakdown is in saving the cost of dressings, possible admission to the hospital, medication and more.”

“This can be accomplished through best practice tool kits that provide for benchmarking knowledge and testing prior to and after the educational process,” Fleck said.

Easy does it
Medline's Pressure Ulcer Prevention Program, offered as a tool for customers, provides comprehensive training that includes simulation tools, such as computer-based head-to-toe assessments that are tracked and managed by a dedicated Medline service rep via Medline University.

“The PUP program makes the problem of not having an expert or specialist on staff a non-issue,” she noted, adding that the training program has been shown to increase staff knowledge by two grade levels, on average.

Sometimes, the greatest skin care successes come from the simplest practices. For Sanctuary at the Shore, that has meant adopting computerized charting with features that allow staff to instantly alert the multidisciplinary care team to changes in the condition of residents' skin.

Whenever a perceived or suspected skin change is detected, the CNAs simply click the “Stop and Watch” button and provide a brief description of the skin change, along with its location. From there, an e-mail alert is automatically sent to Hayes and other members of the interdisciplinary care team.

When Hayes receives the alert, she follows up with the licensed nurse to ensure that a skin assessment is performed and that the proper steps are taken if skin breakdown is indeed present.

“We don't expect those frontline workers to be wound experts, and we don't even expect them to remember all the clinical terms, but we want them to be proactive and hit that button any time there appears to be a change on the skin. That can mean a bruise, redness, rash, lesion or other skin issue,” she explained.

“The goal is to empower those frontline workers and help them do their part to stop problems in their early stages. Even if they're unsure that what they're seeing is actually a change in the skin or early sign of skin breakdown, we want them to keep us informed. And we always thank them for taking the time to report it, even if it turns out to be nothing.”

Breaking bad habits
While skin care techniques should ideally target prevention, an incident of skin breakdown can serve as a valuable training tool.

“Direct care staff should be shown the outcomes of poor care,” said Ann Keren-Zvi, MSN, NP, a wound care specialist who serves as a consultant for the Los Angeles Jewish Home.

Often, poor care isn't deliberate but rather stems from lingering skin care myths and bad habits, some of which may have originated from misinformation and insufficient training. Incontinence care is a prime example.

“Protocols relating to checks and changes and skin wellness are essential in the long-term care setting. Checking underpads and briefs frequently to see if they are soiled goes a long way in promoting skin wellness,” stressed Morgan Pearson, product manager of incontinence care at Covidien.

During changes, frontline caregivers should ensure they have applied briefs and underpads correctly, avoiding bunching that could cause pressure points. They also should understand the importance of proper skin cleansing, moisturizing and the application of barrier cream, as needed.

Some all too common caregiver mistakes, according to Pearson, include using products for incontinence and perineal care that weren't created for that purpose, and relying on traditional soap and washcloth cleaning, which can dry the skin and raise pH levels.

“Products that are not pH balanced to adult skin can directly contribute to skin irritation and breakdown,” Pearson stressed.

Incontinence care is a top priority at the Jewish Home, as is targeted training on pressure reduction and barrier protection.

“Having a coordinated plan to change [residents] as soon as possible when they have soiled themselves is a huge deal,” stressed Clinic Physician Esiquio Casillas.

Little things matter
The care team also must recognize that even slight changes in physiological and cognitive status can spell big trouble for a resident's skin. Nutrition and hydration are critical to skin health, although this is often overlooked, Keren-Zvi said.

“Another problematic area is not looking at how long people sit in wheelchairs. Residents who are incontinent and cannot move should not sit longer than two hours,” she explained.

About 60,000 elderly or disabled Medicaid recipients in Louisiana are being told they should expect to lose their benefits in July, and advocates say more than a quarter of them could be forced out of the long-term care facilities they call home.